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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602144
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:57:41 PM

Document Has Been Signed on 01/24/2023 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:E & E SUNSHINE MANOR IIFACILITY NUMBER:
197602144
ADMINISTRATOR:ERNESTO O. LUCCONFACILITY TYPE:
740
ADDRESS:740 NORTH PARISH PLACETELEPHONE:
(818) 842-9577
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 4DATE:
01/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Josefina Lacsamana. AdministratorTIME COMPLETED:
04:11 PM
NARRATIVE
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LPA made subsequent visit to facility to complete annual inspection that was initialed on 12/29/2022 and was not completed due to time constraints, LPA met with administrator Josefina Lacsamana and explained the purpose of the visit.

During subsequent visit LPA made another tour of facility and observed holes in 4 window screens, staff not wearing mask upon entry during visit of 12/29/2022. Also, there are many discarded items by the garage which pose a potential health, safety or personal rights risk to persons in care.

(deficiencies cited, please 809D for details)

Exit interview conducted with administrator and copy of report and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/24/2023 03:57 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/24/2023 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: E & E SUNSHINE MANOR II
FACILITY NUMBER: 197602144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 staff not wearing face mask in the facility on 12/29/2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2023
Plan of Correction
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Administtrator will conduct training on infection control practicies and send signed rosters as proof to LPA by POC date,
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 4 window screen are in need of repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Administrator will repair or replace 4 window screens and send photos as proof to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/24/2023 03:57 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/24/2023 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: E & E SUNSHINE MANOR II
FACILITY NUMBER: 197602144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Many items are discarded by the garage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Administrator will remove/discard all items by the garage and send proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3